This study discusses the experiences of a single institution in using failure mode and effects analysis (FMEA) to develop strategies for reducing the risk of chemotherapeutic medication errors. The authors outline the operational steps in assembling a FMEA team, a detailed account of the process itself, and the mechanism by which they categorized their recommendations (ie, prescribing, dispensing, and administration). They further discuss the results of their experience, the strategies that were developed, and the postimplementation results. These results included a decreased error rate in prescribing, an increased use of preprinted order sets, and a decreasing number of dispensing and administration errors.